1. Outcome of Increasingly Morbid Cardiac Patients Prof. Abdulhamid Al-Saeed, FFARCSI Professor in Anaesthesia & Critical Care Medicine Head of Cardiac Anaesthesia Department King Fahad Cardiac Center College of Medicine King Saud University

2. Current Population Patient Aspect Elderly Elderly Co-Morbidities Co-Morbidities Cardiac Aspect Repeated PCIs Repeated PCIs Exhausted Medical Therapy Exhausted Medical Therapy Marked LV Dysfunction Marked LV Dysfunction Poor Target vessels with multiple lesions Poor Target vessels with multiple lesions

3. Outcome Scope Morbidity & Mortality The easiest to measure Economic impact Resource utilization & Length of Stay Patient satisfaction & Quality of life Postoperative & Post-discharge followup

4. The Elderly Primarily effect on outcome is the ECONOMIC IMPACT Reduced vital organ reserve Exhaust resources Prolonged stay Secondarily, more prone for Complications Thirdly, is improvement in quality of life in uncomplicated cases in uncomplicated cases

5. Immunological Aspects in Elderly More prone for Postoperative Nosocomial Infections In order of Frequency:  Ventilator Associated Pneumonia ( VAP )  Urinary Tract Infections ( UTIs )  Bactraemia ( may complicate to sepsis )  Wound infection

6. Additional Factors that increases risk  Duration of Mechanical Ventilation  Duration of Urinary Catheterization  Duration of Central Vein Catheterization  Empirical Antibiotic Therapy ( Crucial Debate )

7. Postoperative Course in Elderly Anticipation Prophylactic Measures Prophylactic Measures Proactive Management Proactive Management Atrial Fibrillation ( 30 – 50% of Patients ) Pleural Effusion ( upto 60% of Patients )

8. Protective Strategies in Elderly Management Protective Strategies in Elderly Management

9. Surgical Concern Least wound exposure ( Vein Harvesting ) Least wound exposure ( Vein Harvesting ) Avoid CPB ( OPCAB Technique ) Avoid CPB ( OPCAB Technique ) Benefit: Benefit: Calcified Aorta ( Neurological ) Calcified Aorta ( Neurological ) Hepato-Renal Axis Hepato-Renal Axis Immunological Concern Immunological Concern

10. Anaesthetic Concern  Preoperative optimization of Co-Morbidities  Least invasive monitoring tools  Lung protective ventilation  Critical Perfusion pressure ( Vital Organ Reserve )  Qualitative & Quantitative Pharmacotherapy  Implementation of Fast-Track principle

11. Co-Morbidities In Cardiac Patients Evidently Based affect outcome increased Mortality up to 18% increased Mortality up to 18%  Diabetes Mellitus (↑ Incidence in developing countries )  Arteriopathies ( Carotids )  Renal Impairment ( Dialysis Dependent )  Chronic lung disease ( Pulmonary Pressure )  Obesity ( BMI > 31 ) ALL BEING APART OF CARDIAC CONDITION

12. Data-base Analysis Disease Prevalence

13. Prediction of Outcome Prediction Tools not only dealing with  Anticipating prognosis  Identifying risk to patient or his relatives  Preparing special setup Weighing Surgical Risk / Benefit against Patient Cardiac condition

14. Risk Assessment  The Montreal Heart Model (1983)  The Parsonnet Model ( 1989 )  The Society of Thoracic Surgeons (STS) Database ( 1992 )  The Cleveland Clinic Preoperative Model ( 1994)  The European System for Cardiac Operative Risk Evaluation, Euro-SCORE ( 1999 )

15. The Euro-SCORE, doesn't match our risk in the middle-east as being deficient of two major and prevalent Co-Morbidities Diabetes mellitus Diabetes mellitus Obesity Obesity The Parsonnet Additive Risk Stratification Model Is the most informative and practical

17. Do we have to create our own Model ? The advantage of using a single institution Risk Assessment Tool is that it minimizes variability due to local Treatment Practices.

18. “CABDEAL” Model  C = Creatinine > 110 mmol/L (score 2)  A = Age over 70 years (score 1)  B = BMI > 31 (score 1)  D = DIABETES (score 2)  E = EMERGENCY (score 2)  A = Arrhythmia preoperatively (score 1)  L = Chronic lung disease (score 1)

19. Conclusion  Accurate Implementation of Risk Assessment  Joined Decision-Making to weigh the Risk/Benefit  Take time preoperatively in optimizing your patient, better than to take time postoperatively managing consequences  Frequent Audits to evaluate results and improve practice  Periodical Institutional Data-Base Analysis